Healthcare Provider Details

I. General information

NPI: 1578008769
Provider Name (Legal Business Name): RANDI LEIGH BERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2016
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E CUMBERLAND RD
ALTAMONT IL
62411-1271
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 618-483-6151
  • Fax: 618-483-6153
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.016197
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-016197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: